This form contains 627 fields organized into 130 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
10A Diagnostic imaging performed/reviewed (Yes/No)
Yes	Radiobutton	Check this box if clinically relevant diagnostic imaging studies or other diagnostic procedures have been performed or reviewed in conjunction with this examination.
No	Radiobutton	Check this box if no clinically relevant diagnostic imaging studies or other diagnostic procedures were performed or reviewed in conjunction with this examination.
10B Degenerative or post-traumatic arthritis documented and side (Yes/No, Right/Left/Both)
Yes	Radiobutton	Check this box if degenerative or post-traumatic arthritis is documented (confirmed by imaging).
No	Radiobutton	Check this box if degenerative or post-traumatic arthritis is not documented.
Right	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis affects the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis affects the left side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis affects both sides. Fill only if 'Yes' is 'Yes'. Depends on: Yes
10C Imaging/test/procedure details (type, date, results summary)
Imaging/Test/Procedure Details	Text	Enter the type of diagnostic imaging study, test, or procedure performed or reviewed, the date it occurred, and a brief summary of the results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
10D Other diagnostic test findings reviewed (Yes/No) and details
Yes	Radiobutton	Check this box if other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) were reviewed in conjunction with this examination.
No	Radiobutton	Check this box if no other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) were reviewed in conjunction with this examination.
Other Diagnostic Test Findings Details	Text	Provide the type of other diagnostic test or procedure reviewed, the date it was performed, and a brief summary of the results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
10E Relationship of abnormal findings to diagnosed conditions
Relationship of Abnormal Findings to Diagnosed Conditions	Text	Describe how any abnormal diagnostic test findings are related to the diagnosed condition(s), including which condition each abnormal result supports or is attributable to.
5B Comments (Left)
5B Comments	Text	Enter any additional comments or explanations for item 5B, if applicable.
5B Comments (Right)
5B Comments	Text	Enter any additional comments or notes for item 5B, if applicable.
6A Arthroscopic/Other Wrist Surgery Details (Left)
Left Wrist Surgery Type	Text	Enter the type of arthroscopic or other wrist surgery performed on the left wrist. Fill only if 'Arthroscopic or other wrist surgery' is 'Yes'. Depends on: Arthroscopic or other wrist surgery
Left Wrist Surgery Date	Date	Enter the date the arthroscopic or other left wrist surgery was performed. Fill only if 'Arthroscopic or other wrist surgery' is 'Yes'. Depends on: Arthroscopic or other wrist surgery
Left Wrist Surgery Residuals Description	Text	Describe any ongoing residuals or symptoms resulting from the arthroscopic or other left wrist surgery. Fill only if 'Arthroscopic or other wrist surgery' is 'Yes'. Depends on: Arthroscopic or other wrist surgery
6A Arthroscopic/Other Wrist Surgery Details (Right)
Type of wrist surgery (right)	Text	Enter the type of arthroscopic or other wrist surgery performed on the right wrist. Fill only if 'Arthroscopic or other wrist surgery' is 'Yes'. Depends on: Arthroscopic or other wrist surgery
Date of wrist surgery (right)	Date	Enter the date the arthroscopic or other right wrist surgery was performed. Fill only if 'Arthroscopic or other wrist surgery' is 'Yes'. Depends on: Arthroscopic or other wrist surgery
Residuals description (right wrist surgery)	Text	Describe any residual symptoms or limitations resulting from the right wrist surgery. Fill only if 'Arthroscopic or other wrist surgery' is 'Yes'. Depends on: Arthroscopic or other wrist surgery
6A Surgical Procedures Selected (Left)
No surgery	Checkbox	Check this box if the Veteran has not had any surgical procedures for the left wrist/hand condition.
Total wrist joint replacement	Checkbox	Check this box if the Veteran has had a total wrist joint replacement on the left side.
Arthroscopic or other wrist surgery	Checkbox	Check this box if the Veteran has had arthroscopic surgery or any other wrist surgery on the left side.
6A Surgical Procedures Selected (Right)
No surgery	Checkbox	Check this box if the Veteran has not had any surgical procedures on the right wrist.
Total wrist joint replacement	Checkbox	Check this box if the Veteran has had a total wrist joint replacement on the right wrist.
Arthroscopic or other wrist surgery	Checkbox	Check this box if the Veteran has had arthroscopic or any other type of surgery on the right wrist (other than total wrist joint replacement).
6A Total Wrist Joint Replacement Details (Left)
Total Wrist Joint Replacement Date (Left)	Date	Enter the date the Veteran had the left total wrist joint replacement surgery. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: None	Checkbox	Check this box if the Veteran has no residual symptoms or limitations following the left total wrist joint replacement. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if the Veteran has intermediate (moderate) residual weakness, pain, or limitation of motion after the left total wrist joint replacement. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the Veteran has chronic severe painful motion or weakness as residuals of the left total wrist joint replacement. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: Other residuals (describe)	Checkbox	Check this box if the Veteran has residuals from the left total wrist joint replacement that are not covered by the options above and will be described in the space provided. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Other Residuals Description (Left Wrist Replacement)	Text	Describe any other residual symptoms or functional limitations resulting from the left total wrist joint replacement. Fill only if 'Residuals: Other residuals (describe)' is 'Yes'. Depends on: Residuals: Other residuals (describe)
6A Total Wrist Joint Replacement Details (Right)
Total Wrist Joint Replacement Surgery Date (Right)	Date	Enter the date the Veteran had the right total wrist joint replacement surgery. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: None	Checkbox	Check this box if the Veteran has no residual symptoms or limitations following the right total wrist joint replacement. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if the Veteran has intermediate (moderate) residual weakness, pain, and/or limited motion after the right total wrist joint replacement. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the Veteran has chronic residuals with severe painful motion and/or severe weakness after the right total wrist joint replacement. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Residuals: Other residuals (describe)	Checkbox	Check this box if the Veteran has residuals not listed above following the right total wrist joint replacement and you will describe them in the space provided. Fill only if 'Total wrist joint replacement' is 'Yes'. Depends on: Total wrist joint replacement
Other Residuals Description (Right Wrist Replacement)	Text	Describe any other residuals or ongoing symptoms following the right total wrist joint replacement. Fill only if 'Residuals: Other residuals (describe)' is 'Yes'. Depends on: Residuals: Other residuals (describe)
7A Other Pertinent Findings (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.
No	Radiobutton	Check this box if the Veteran has no other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.
Other Pertinent Findings Description	Text	Provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
7B. Does the Veteran have any scars or other disfigurement (of the skin) related to any conditions or to the treatment of any conditions listed in the diagnosis
Yes	Radiobutton	Check this box if the Veteran has any scars or other skin disfigurement related to any diagnosed condition or its treatment.
No	Radiobutton	Check this box if the Veteran does not have any scars or other skin disfigurement related to any diagnosed condition or its treatment.
Additional Wrist Diagnoses (1C)
Additional Wrist Diagnoses	Text	Enter any additional wrist-related diagnoses not already listed above, using the same format as the diagnosis entries above (including side affected, ICD code, and date of diagnosis if applicable).
Ankylosis of wrist Diagnosis
Ankylosis of wrist	Checkbox	Check this box if the Veteran has a current diagnosis of ankylosis of the wrist.
Ankylosis of wrist - Right	Radiobutton	Check this box if the ankylosis of the wrist affects the right wrist. Fill only if 'Ankylosis of wrist' is 'Yes'. Depends on: Ankylosis of wrist
Ankylosis of wrist - Left	Radiobutton	Check this box if the ankylosis of the wrist affects the left wrist. Fill only if 'Ankylosis of wrist' is 'Yes'. Depends on: Ankylosis of wrist
Ankylosis of wrist - Both	Radiobutton	Check this box if the ankylosis of the wrist affects both wrists. Fill only if 'Ankylosis of wrist' is 'Yes'. Depends on: Ankylosis of wrist
Ankylosis of Wrist ICD Code	Text	Enter the ICD diagnostic code for the ankylosis of the wrist diagnosis. Fill only if 'Ankylosis of wrist' is 'Yes'. Depends on: Ankylosis of wrist
Ankylosis of Wrist Diagnosis Date (Right)	Date	Enter the date the ankylosis of the right wrist was diagnosed. Fill only if 'Ankylosis of wrist' is 'Yes'. Depends on: Ankylosis of wrist
Ankylosis of Wrist Diagnosis Date (Left)	Date	Enter the date the ankylosis of the left wrist was diagnosed. Fill only if 'Ankylosis of wrist' is 'Yes'. Depends on: Ankylosis of wrist
Arthritis, gonorrheal Diagnosis
Arthritis, gonorrheal	Checkbox	Check this box if the claimed condition includes a diagnosis of gonorrheal arthritis.
Side affected - Right	Radiobutton	Check this box if the gonorrheal arthritis affects the right wrist/side only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Side affected - Left	Radiobutton	Check this box if the gonorrheal arthritis affects the left wrist/side only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Side affected - Both	Radiobutton	Check this box if the gonorrheal arthritis affects both wrists/sides. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
ICD Code	Text	Enter the ICD diagnostic code for the gonorrheal arthritis condition. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Date of Diagnosis (Right)	Date	Enter the date the gonorrheal arthritis was diagnosed for the right side. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Date of Diagnosis (Left)	Date	Enter the date the gonorrheal arthritis was diagnosed for the left side. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Arthritis, pneumococcic Diagnosis
Arthritis, pneumococcic	Checkbox	Check this box if the Veteran has a diagnosis of pneumococcic arthritis related to the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if pneumococcic arthritis affects the right wrist/hand. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected: Left	Radiobutton	Check this box if pneumococcic arthritis affects the left wrist/hand. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected: Both	Radiobutton	Check this box if pneumococcic arthritis affects both wrists/hands. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic ICD Code	Text	Enter the ICD diagnostic code for arthritis, pneumococcic. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic Date of Diagnosis (Right)	Date	Enter the date of diagnosis for arthritis, pneumococcic affecting the right side. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic Date of Diagnosis (Left)	Date	Enter the date of diagnosis for arthritis, pneumococcic affecting the left side. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, rheumatoid (multi-joints) Diagnosis
Arthritis, rheumatoid (multi-joints)	Checkbox	Check this box if the Veteran has a diagnosis of rheumatoid arthritis affecting multiple joints related to the claimed condition.
Side affected: Right	Radiobutton	Check this box if the rheumatoid arthritis (multi-joints) affects the right side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Side affected: Left	Radiobutton	Check this box if the rheumatoid arthritis (multi-joints) affects the left side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Side affected: Both	Radiobutton	Check this box if the rheumatoid arthritis (multi-joints) affects both sides. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
ICD Code (Rheumatoid arthritis, multi-joints)	Text	Enter the ICD diagnostic code for the Veteran’s rheumatoid arthritis (multi-joints). Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Date of Diagnosis – Right (Rheumatoid arthritis, multi-joints)	Date	Provide the date the Veteran was diagnosed with rheumatoid arthritis (multi-joints) affecting the right side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Date of Diagnosis – Left (Rheumatoid arthritis, multi-joints)	Date	Provide the date the Veteran was diagnosed with rheumatoid arthritis (multi-joints) affecting the left side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Arthritis, streptococcic Diagnosis
Arthritis, streptococcic	Checkbox	Check this box if the Veteran has a diagnosis of streptococcic arthritis associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the streptococcic arthritis affects the right wrist. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Side affected: Left	Radiobutton	Check this box if the streptococcic arthritis affects the left wrist. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Side affected: Both	Radiobutton	Check this box if the streptococcic arthritis affects both wrists. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Streptococcic arthritis ICD code	Text	Enter the ICD diagnostic code for the Veteran’s streptococcic arthritis. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Streptococcic arthritis date of diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with streptococcic arthritis affecting the right side. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Streptococcic arthritis date of diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with streptococcic arthritis affecting the left side. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Arthritis, syphilitic Diagnosis
Both	Radiobutton	Check this box if the Veteran’s syphilitic arthritis affects both the right and left side (both wrists). Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Syphilitic arthritis ICD code	Text	Enter the ICD diagnosis code for syphilitic arthritis. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Syphilitic arthritis date of diagnosis (right)	Date	Enter the date syphilitic arthritis was diagnosed for the right side. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Syphilitic arthritis date of diagnosis (left)	Date	Enter the date syphilitic arthritis was diagnosed for the left side. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, typhoid Diagnosis
Arthritis, typhoid	Checkbox	Check this box if the Veteran has (or is being diagnosed with) typhoid-related arthritis as a claimed wrist condition.
Side affected: Right	Radiobutton	Check this box if typhoid-related arthritis affects the right wrist only. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Side affected: Left	Radiobutton	Check this box if typhoid-related arthritis affects the left wrist only. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Side affected: Both	Radiobutton	Check this box if typhoid-related arthritis affects both wrists. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid ICD Code	Text	Enter the ICD diagnostic code corresponding to the claimed condition of arthritis due to typhoid. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid Date of Diagnosis (Right)	Date	Provide the date this condition was diagnosed for the right side. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid Date of Diagnosis (Left)	Date	Provide the date this condition was diagnosed for the left side. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Assistive Devices by Condition/Side (Narrative)
Assistive Devices by Condition and Side	Text	Describe each condition for which the Veteran uses an assistive device, indicating the affected side (e.g., left/right/bilateral) and the specific assistive device used for that condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Assistive Devices Used (Yes/No)
Yes	Radiobutton	Check this box if the Veteran uses any assistive devices.
No	Radiobutton	Check this box if the Veteran does not use any assistive devices.
Avascular necrosis of carpal bones Diagnosis
Avascular necrosis of carpal bones	Checkbox	Check this box if the Veteran is diagnosed with avascular necrosis of the carpal bones.
Avascular necrosis of carpal bones - Right	Radiobutton	Check this box if avascular necrosis of the carpal bones affects the right wrist. Fill only if 'Avascular necrosis of carpal bones' is 'Yes'. Depends on: Avascular necrosis of carpal bones
Avascular necrosis of carpal bones - Left	Radiobutton	Check this box if avascular necrosis of the carpal bones affects the left wrist. Fill only if 'Avascular necrosis of carpal bones' is 'Yes'. Depends on: Avascular necrosis of carpal bones
Avascular necrosis of carpal bones - Both	Radiobutton	Check this box if avascular necrosis of the carpal bones affects both wrists. Fill only if 'Avascular necrosis of carpal bones' is 'Yes'. Depends on: Avascular necrosis of carpal bones
Avascular Necrosis (Carpal Bones) ICD Code	Text	Enter the ICD diagnosis code for avascular necrosis of the carpal bones. Fill only if 'Avascular necrosis of carpal bones' is 'Yes'. Depends on: Avascular necrosis of carpal bones
Avascular Necrosis (Carpal Bones) Date of Diagnosis (Right)	Date	Enter the date avascular necrosis of the carpal bones was diagnosed for the right side. Fill only if 'Avascular necrosis of carpal bones' is 'Yes'. Depends on: Avascular necrosis of carpal bones
Avascular Necrosis (Carpal Bones) Date of Diagnosis (Left)	Date	Enter the date avascular necrosis of the carpal bones was diagnosed for the left side. Fill only if 'Avascular necrosis of carpal bones' is 'Yes'. Depends on: Avascular necrosis of carpal bones
Bones, neoplasm (benign) Diagnosis
Bones, neoplasm, benign	Checkbox	Check this box if the Veteran has a diagnosis of a benign bone neoplasm related to the claimed condition.
Side affected: Right	Radiobutton	Check this box if the benign bone neoplasm affects the right side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Side affected: Left	Radiobutton	Check this box if the benign bone neoplasm affects the left side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Side affected: Both	Radiobutton	Check this box if the benign bone neoplasm affects both sides. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
ICD Code (Benign Bone Neoplasm)	Text	Enter the ICD diagnosis code for the benign bone neoplasm condition. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Date of Diagnosis (Right)	Date	Enter the date the benign bone neoplasm was diagnosed for the right side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Date of Diagnosis (Left)	Date	Enter the date the benign bone neoplasm was diagnosed for the left side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Brace and Frequency of Use
Brace	Checkbox	Check this box if the Veteran uses a brace as an assistive device. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Frequency of use: Occasional	Radiobutton	Select this option if the Veteran uses the brace occasionally. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Frequency of use: Regular	Radiobutton	Select this option if the Veteran uses the brace regularly. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Frequency of use: Constant	Radiobutton	Select this option if the Veteran uses the brace constantly. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Bursitis Diagnosis
Bursitis	Checkbox	Check this box if the claimed condition includes a diagnosis of bursitis.
Bursitis - Right	Radiobutton	Select this option if the diagnosed bursitis affects the right side. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis - Left	Radiobutton	Select this option if the diagnosed bursitis affects the left side. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis - Both	Radiobutton	Select this option if the diagnosed bursitis affects both sides. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis ICD Code	Text	Enter the ICD diagnostic code corresponding to the bursitis diagnosis. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis Date of Diagnosis (Right)	Date	Provide the date when bursitis was diagnosed for the right side. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis Date of Diagnosis (Left)	Date	Provide the date when bursitis was diagnosed for the left side. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Carpal instability Diagnosis
Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)	Checkbox	Check this box if the Veteran has a diagnosis of carpal instability (intercalated segment, midcarpal, or scapholunate dissociation) associated with the claimed condition.
Carpal instability side affected: Right	Radiobutton	Check this box if the diagnosed carpal instability affects the right wrist. Fill only if 'Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)' is 'Yes'. Depends on: Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)
Carpal instability side affected: Left	Radiobutton	Check this box if the diagnosed carpal instability affects the left wrist. Fill only if 'Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)' is 'Yes'. Depends on: Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)
Carpal instability side affected: Both	Radiobutton	Check this box if the diagnosed carpal instability affects both wrists. Fill only if 'Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)' is 'Yes'. Depends on: Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)
Carpal Instability ICD Code	Text	Enter the ICD diagnostic code for the carpal instability diagnosis. Fill only if 'Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)' is 'Yes'. Depends on: Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)
Carpal Instability Date of Diagnosis (Right)	Date	Enter the date the carpal instability was diagnosed for the right wrist. Fill only if 'Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)' is 'Yes'. Depends on: Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)
Carpal Instability Date of Diagnosis (Left)	Date	Enter the date the carpal instability was diagnosed for the left wrist. Fill only if 'Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)' is 'Yes'. Depends on: Carpal instability (intercalated segment/midcarpal/scapholunate dissociation)
Carpal metacarpal (CMC) arthritis Diagnosis
Carpal metacarpal (CMC) arthritis	Checkbox	Check this box if the Veteran is diagnosed with carpal metacarpal (CMC) arthritis.
CMC arthritis - Side affected: Right	Radiobutton	Check this box if the Veteran’s CMC arthritis affects the right side. Fill only if 'Carpal metacarpal (CMC) arthritis' is 'Yes'. Depends on: Carpal metacarpal (CMC) arthritis
CMC arthritis - Side affected: Left	Radiobutton	Check this box if the Veteran’s CMC arthritis affects the left side. Fill only if 'Carpal metacarpal (CMC) arthritis' is 'Yes'. Depends on: Carpal metacarpal (CMC) arthritis
CMC arthritis - Side affected: Both	Radiobutton	Check this box if the Veteran’s CMC arthritis affects both sides. Fill only if 'Carpal metacarpal (CMC) arthritis' is 'Yes'. Depends on: Carpal metacarpal (CMC) arthritis
CMC Arthritis ICD Code	Text	Enter the ICD diagnosis code for carpal metacarpal (CMC) arthritis. Fill only if 'Carpal metacarpal (CMC) arthritis' is 'Yes'. Depends on: Carpal metacarpal (CMC) arthritis
CMC Arthritis Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with carpal metacarpal (CMC) arthritis affecting the right side. Fill only if 'Carpal metacarpal (CMC) arthritis' is 'Yes'. Depends on: Carpal metacarpal (CMC) arthritis
CMC Arthritis Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with carpal metacarpal (CMC) arthritis affecting the left side. Fill only if 'Carpal metacarpal (CMC) arthritis' is 'Yes'. Depends on: Carpal metacarpal (CMC) arthritis
Claimed Wrist Condition(s) (1A)
Claimed Wrist Condition(s)	Text	Enter the wrist condition(s) being claimed that pertain to this questionnaire (e.g., specific diagnosis names).
Degenerative arthritis (other than posttraumatic) Diagnosis
Degenerative arthritis, other than posttraumatic	Checkbox	Check this box if the Veteran has a diagnosis of degenerative arthritis that is not posttraumatic.
Side affected: Right	Radiobutton	Check this box if degenerative arthritis (other than posttraumatic) affects the right wrist. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'. Depends on: Degenerative arthritis, other than posttraumatic
Side affected: Left	Radiobutton	Check this box if degenerative arthritis (other than posttraumatic) affects the left wrist. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'. Depends on: Degenerative arthritis, other than posttraumatic
Side affected: Both	Radiobutton	Check this box if degenerative arthritis (other than posttraumatic) affects both wrists. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'. Depends on: Degenerative arthritis, other than posttraumatic
ICD Code	Text	Enter the ICD diagnosis code for degenerative arthritis (other than posttraumatic) of the wrist. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'. Depends on: Degenerative arthritis, other than posttraumatic
Date of Diagnosis (Right Wrist)	Date	Provide the date when degenerative arthritis (other than posttraumatic) was diagnosed for the right wrist. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'. Depends on: Degenerative arthritis, other than posttraumatic
Date of Diagnosis (Left Wrist)	Date	Provide the date when degenerative arthritis (other than posttraumatic) was diagnosed for the left wrist. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'. Depends on: Degenerative arthritis, other than posttraumatic
DeQuervain's syndrome Diagnosis
DeQuervain's syndrome	Checkbox	Check this box if the Veteran has a current diagnosis of DeQuervain's syndrome associated with the claimed wrist condition.
DeQuervain's syndrome - Side affected: Right	Radiobutton	Check this box if DeQuervain's syndrome affects the Veteran's right wrist/hand. Fill only if 'DeQuervain's syndrome' is 'Yes'. Depends on: DeQuervain's syndrome
DeQuervain's syndrome - Side affected: Left	Radiobutton	Check this box if DeQuervain's syndrome affects the Veteran's left wrist/hand. Fill only if 'DeQuervain's syndrome' is 'Yes'. Depends on: DeQuervain's syndrome
DeQuervain's syndrome - Side affected: Both	Radiobutton	Check this box if DeQuervain's syndrome affects both wrists/hands. Fill only if 'DeQuervain's syndrome' is 'Yes'. Depends on: DeQuervain's syndrome
DeQuervain's Syndrome ICD Code	Text	Enter the ICD diagnosis code for DeQuervain's syndrome. Fill only if 'DeQuervain's syndrome' is 'Yes'. Depends on: DeQuervain's syndrome
DeQuervain's Syndrome Date of Diagnosis (Right)	Date	Enter the date DeQuervain's syndrome was diagnosed for the right side. Fill only if 'DeQuervain's syndrome' is 'Yes'. Depends on: DeQuervain's syndrome
DeQuervain's Syndrome Date of Diagnosis (Left)	Date	Enter the date DeQuervain's syndrome was diagnosed for the left side. Fill only if 'DeQuervain's syndrome' is 'Yes'. Depends on: DeQuervain's syndrome
DOMINANT HAND
Right	Radiobutton	Check this box if the veteran’s dominant hand is the right hand.
Left	Radiobutton	Check this box if the veteran’s dominant hand is the left hand.
Ambidextrous	Radiobutton	Check this box if the veteran uses both hands equally as the dominant hand.
EVIDENCE REVIEW
No records were reviewed	Radiobutton	Check this box if you did not review any records/evidence when completing this questionnaire.
Records reviewed	Radiobutton	Check this box if you reviewed any records/evidence (e.g., service treatment records, VA treatment records, private treatment records) when completing this questionnaire.
Evidence Reviewed Details	Text	List the specific records or evidence reviewed (e.g., service treatment records, VA treatment records, private treatment records) and include the applicable date range. Fill only if 'Records reviewed' is 'Yes'. Depends on: Records reviewed
Examiner Contact and Credentials
Examiner Phone/Fax Numbers	Text	Enter the examiner’s phone number and/or fax number.
NPI Number	Text	Enter the examiner’s National Provider Identifier (NPI) number.
Medical License Number and State	Text	Enter the examiner’s medical license number and the issuing state.
Examiner Address	Text	Enter the examiner’s full mailing address.
Examiner Name and Specialty
Examiner Printed Name and Title	Text	Enter the examiner’s printed name and professional title/credentials (e.g., MD, DO, NP).
Examiner Specialty / Area of Practice	Text	Enter the examiner’s medical specialty or area of practice (e.g., Cardiology, Orthopedics, General Practice).
Examiner Signature and Date
Examiner Signature	Text	Enter the examiner’s signature to certify the information provided in this form.
Date Signed	Date	Enter the date the examiner signed this form.
Functional Loss Equivalent to Amputation (Q9A Response and Affected Extremities)
Yes (functional loss equivalent to amputation with prosthesis)	Radiobutton	Check this box if the Veteran’s upper-extremity function is so diminished that amputation with prosthesis would equally serve the Veteran.
No	Radiobutton	Check this box if the Veteran does not have functional loss of an upper extremity equivalent to amputation with prosthesis.
Right upper	Checkbox	If 'Yes' is selected for Q9A, check this box to indicate the right upper extremity is affected. Fill only if 'Yes (functional loss equivalent to amputation with prosthesis)' is 'Yes'. Depends on: Yes (functional loss equivalent to amputation with prosthesis)
Left upper	Checkbox	If 'Yes' is selected for Q9A, check this box to indicate the left upper extremity is affected. Fill only if 'Yes (functional loss equivalent to amputation with prosthesis)' is 'Yes'. Depends on: Yes (functional loss equivalent to amputation with prosthesis)
Functional Loss/Impairment Reported (Question 2C)
Yes	Radiobutton	Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity being evaluated, including after repeated use over time.
No	Radiobutton	Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated, including after repeated use over time.
Veteran Functional Loss/Impairment Description	Text	Enter the Veteran’s own words describing any functional loss or functional impairment of the evaluated joint or extremity, including effects after repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Ganglion cyst Diagnosis
Ganglion cyst	Checkbox	Check this box if the Veteran has a diagnosis of a ganglion cyst associated with the claimed wrist condition(s).
Ganglion cyst — Right side affected	Radiobutton	Check this box if the diagnosed ganglion cyst affects the right wrist/hand. Fill only if 'Ganglion cyst' is 'Yes'. Depends on: Ganglion cyst
Ganglion cyst — Left side affected	Radiobutton	Check this box if the diagnosed ganglion cyst affects the left wrist/hand. Fill only if 'Ganglion cyst' is 'Yes'. Depends on: Ganglion cyst
Ganglion cyst — Both sides affected	Radiobutton	Check this box if the diagnosed ganglion cyst affects both the right and left wrists/hands. Fill only if 'Ganglion cyst' is 'Yes'. Depends on: Ganglion cyst
Ganglion cyst ICD code	Text	Enter the ICD diagnosis code corresponding to the ganglion cyst. Fill only if 'Ganglion cyst' is 'Yes'. Depends on: Ganglion cyst
Ganglion cyst date of diagnosis (Right)	Date	Enter the date the ganglion cyst was diagnosed for the right side. Fill only if 'Ganglion cyst' is 'Yes'. Depends on: Ganglion cyst
Ganglion cyst date of diagnosis (Left)	Date	Enter the date the ganglion cyst was diagnosed for the left side. Fill only if 'Ganglion cyst' is 'Yes'. Depends on: Ganglion cyst
Gout Diagnosis
Gout	Checkbox	Check this box if the Veteran has a diagnosis of gout associated with the claimed condition(s).
Gout - Right side affected	Radiobutton	Check this box if the Veteran’s gout affects the right side. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout - Left side affected	Radiobutton	Check this box if the Veteran’s gout affects the left side. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout - Both sides affected	Radiobutton	Check this box if the Veteran’s gout affects both sides. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout ICD Code	Text	Enter the ICD diagnostic code associated with the Veteran's gout diagnosis. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with gout affecting the right side. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with gout affecting the left side. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Heterotopic ossification Diagnosis
Heterotopic ossification	Checkbox	Check this box if the Veteran has a diagnosis of heterotopic ossification associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the heterotopic ossification affects the right wrist/side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Side affected: Left	Radiobutton	Check this box if the heterotopic ossification affects the left wrist/side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Side affected: Both	Radiobutton	Check this box if the heterotopic ossification affects both wrists/sides. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic ossification ICD code	Text	Enter the ICD diagnosis code associated with the Veteran’s heterotopic ossification. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic ossification diagnosis date (Right)	Date	Provide the date the Veteran was diagnosed with heterotopic ossification affecting the right side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic ossification diagnosis date (Left)	Date	Provide the date the Veteran was diagnosed with heterotopic ossification affecting the left side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Inflammatory (other types) Diagnosis
Inflammatory, other types	Checkbox	Check this box if the Veteran has an inflammatory wrist/hand diagnosis of another type that applies to the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the inflammatory (other types) diagnosis affects the right side. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Side affected: Left	Radiobutton	Check this box if the inflammatory (other types) diagnosis affects the left side. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Side affected: Both	Radiobutton	Check this box if the inflammatory (other types) diagnosis affects both the right and left sides. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Inflammatory Condition ICD Code	Text	Enter the ICD diagnosis code for the inflammatory (other type) condition being claimed. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Inflammatory Condition Diagnosis Date (Right)	Date	Enter the date this inflammatory (other type) condition was diagnosed for the right side. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Inflammatory Condition Diagnosis Date (Left)	Date	Enter the date this inflammatory (other type) condition was diagnosed for the left side. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Inflammatory Condition Type (Specify)	Text	Specify the inflammatory condition type being diagnosed if it is not otherwise listed on the form. Fill only if 'Inflammatory, other types' is 'Yes'. Depends on: Inflammatory, other types
Left - Additional loss after three repetitions
Yes	Radiobutton	Check this box if there is additional loss of function or range of motion after three repetitions (left side). Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if there is no additional loss of function or range of motion after three repetitions (left side). Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'. Depends on: Yes
Dorsiflexion Endpoint After Repetitions (Left)	Text	Enter the left ankle dorsiflexion endpoint measured after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Palmar Flexion Endpoint After Repetitions (Left)	Text	Enter the left wrist palmar flexion endpoint measured after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Ulnar Deviation Endpoint After Repetitions (Left)	Text	Enter the left wrist ulnar deviation endpoint measured after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Radial Deviation Endpoint After Repetitions (Left)	Text	Enter the left wrist radial deviation endpoint measured after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if the listed factors causing functional loss do not apply or are not applicable (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Pain	Checkbox	Check this box if pain causes the additional functional loss after three repetitions (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability causes the additional functional loss after three repetitions (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness causes the additional functional loss after three repetitions (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes the additional functional loss after three repetitions (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination causes the additional functional loss after three repetitions (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other	Checkbox	Check this box if another factor (not listed) causes the additional functional loss after three repetitions (left side). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Factors Causing Functional Loss (Left)	Text	Describe any other factors not listed that cause additional functional loss after three repetitions. Fill only if 'Other' is 'Yes'. Depends on: Other
Left - Repeated use over time: cite and discuss evidence
Repeated Use Over Time Evidence	Text	Cite and discuss the specific evidence used to support the repeated-use-over-time findings, based on all procurable case-specific information.
Left - Repeated use over time: estimated ROM after repeated use
Dorsiflexion endpoint (estimated after repeated use)	Number	Enter the estimated dorsiflexion endpoint range of motion for the joint immediately after repeated use over time. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Palmar flexion endpoint (estimated after repeated use)	Number	Enter the estimated palmar flexion endpoint range of motion for the joint immediately after repeated use over time. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Ulnar deviation endpoint (estimated after repeated use)	Number	Enter the estimated ulnar deviation endpoint range of motion for the joint immediately after repeated use over time. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Radial deviation endpoint (estimated after repeated use)	Number	Enter the estimated radial deviation endpoint range of motion for the joint immediately after repeated use over time. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Left - Repeated use over time: functional loss factors
N/A	Checkbox	Check this box if no listed factors cause functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Pain	Checkbox	Check this box if pain causes functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Fatigability	Checkbox	Check this box if fatigability causes functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Weakness	Checkbox	Check this box if weakness causes functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Incoordination	Checkbox	Check this box if incoordination causes functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Other	Checkbox	Check this box if another factor not listed causes functional loss with repeated use over time for the left side. Fill only if 'Procured evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests functional limitation with repeated use over time - Yes
Other Functional Loss Factor	Text	Describe any other factor(s) causing functional loss with repeated use over time that are not listed in the checkboxes. Fill only if 'Other' is 'Yes'. Depends on: Other
Left - Repeated use over time: immediate exam & evidence yes/no
Exam immediately after repeated use over time - Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time.
Exam immediately after repeated use over time - No	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time.
Procured evidence suggests functional limitation with repeated use over time - Yes	Radiobutton	Check this box if procured evidence (e.g., Veteran statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
Procured evidence suggests functional limitation with repeated use over time - No	Radiobutton	Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
Left Column Additional Contributing Factors (Checkboxes + Other Text)
None	Checkbox	Check this box if there are no additional factors contributing to the disability beyond those already addressed.
Interference with standing	Checkbox	Check this box if the disability causes difficulty or limitation with standing.
Interference with sitting	Checkbox	Check this box if the disability causes difficulty or limitation with sitting.
Disturbance of locomotion	Checkbox	Check this box if the disability disrupts walking or moving from place to place.
Swelling	Checkbox	Check this box if swelling is present as an additional contributing factor.
Less movement than normal	Checkbox	Check this box if the affected area has reduced range of motion compared with normal.
Deformity	Checkbox	Check this box if there is a deformity of the affected area contributing to disability.
Weakened movement	Checkbox	Check this box if weakness causes reduced strength or weakened movement in the affected area.
More movement than normal	Checkbox	Check this box if the affected area has excessive movement or abnormal looseness compared with normal.
Instability of station	Checkbox	Check this box if the disability causes unsteadiness or instability when standing or maintaining posture.
Atrophy of disuse	Checkbox	Check this box if there is muscle wasting (atrophy) due to decreased use of the affected area.
Other, describe	Checkbox	Check this box if another contributing factor applies that is not listed, and provide details in the description field.
Other Additional Factor Description	Text	Enter a description of any other additional factor contributing to the disability that is not listed among the checkboxes. Fill only if 'Other, describe' is 'Yes'. Depends on: Other, describe
Left Column Additional Contributing Factors Narrative
Additional Contributing Factors Description	Text	Provide a detailed narrative describing any additional factors contributing to the disability selected above and how they affect the condition.
Left Column Flare-up Evidence Narrative
Flare-up Evidence Narrative	Text	Provide a narrative citing and discussing the evidence supporting the flare-up assessment, including relevant medical records, lay statements, and any other procurable information. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Left Column Flare-up Functional Loss Causes (Checkboxes + Other Text)
N/A	Checkbox	Check this box if no listed factors cause the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Pain	Checkbox	Check this box if pain causes the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability (easy tiring) causes the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness causes the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination causes the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Other	Checkbox	Check this box if another factor not listed causes the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Other Functional Loss Factor	Text	Enter a brief description of any other factor(s) causing functional loss that are not listed (e.g., pain, fatigability, weakness, lack of endurance, incoordination). Fill only if 'Other' is 'Yes'. Depends on: Other
Left Column Flare-up Yes/No Questions
Exam conducted during a flare-up: Yes	Radiobutton	Check this box if the examination is being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Exam conducted during a flare-up: No	Radiobutton	Check this box if the examination is not being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Evidence suggests functional loss factors with repeated use over time: Yes	Radiobutton	Check this box if the Veteran’s statements/evidence suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Evidence suggests functional loss factors with repeated use over time: No	Radiobutton	Check this box if the Veteran’s statements/evidence do not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Left Column Repeated-Use Range of Motion Estimates
Repeated-Use Dorsiflexion Endpoint (Degrees)	Number	Enter the estimated dorsiflexion endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Repeated-Use Palmar Flexion Endpoint (Degrees)	Number	Enter the estimated palmar flexion endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Repeated-Use Ulnar Deviation Endpoint (Degrees)	Number	Enter the estimated ulnar deviation endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Repeated-Use Radial Deviation Endpoint (Degrees)	Number	Enter the estimated radial deviation endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Left Upper Extremity Atrophy Measurements
Left upper extremity	Checkbox	Check this box if the Veteran has muscle atrophy in the left upper extremity and you will provide the location and circumference measurements as requested.
Left Upper Extremity Atrophy Location	Text	Describe the specific location on the left upper extremity where the atrophy measurement was taken (e.g., a set distance below the anterior elbow crease). Fill only if 'Left upper extremity' is 'Yes'. Depends on: Left upper extremity
Normal Side Circumference (Left Upper Extremity)	Number	Enter the circumference measurement of the more normal side at the specified left upper extremity measurement location. Fill only if 'Left upper extremity' is 'Yes'. Depends on: Left upper extremity
Atrophied Side Circumference (Left Upper Extremity)	Number	Enter the circumference measurement of the atrophied side at the specified left upper extremity measurement location. Fill only if 'Left upper extremity' is 'Yes'. Depends on: Left upper extremity
Left Upper Extremity Muscle Atrophy
Muscle atrophy - Yes	Radiobutton	Check this box if the Veteran has muscle atrophy in the left upper extremity.
Muscle atrophy - No	Radiobutton	Check this box if the Veteran does not have muscle atrophy in the left upper extremity.
Atrophy due to claimed condition - Yes	Radiobutton	Check this box if the left upper extremity muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Muscle atrophy - Yes' is 'Yes'. Depends on: Muscle atrophy - Yes
Atrophy due to claimed condition - No	Radiobutton	Check this box if the left upper extremity muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Muscle atrophy - Yes' is 'Yes'. Depends on: Muscle atrophy - Yes
Rationale if Muscle Atrophy Not Due to Claimed Condition (Left Upper Extremity)	Text	Provide the medical rationale explaining why the Veteran’s left upper extremity muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Atrophy due to claimed condition - No' is 'Yes'. Depends on: Atrophy due to claimed condition - No
Left Wrist - Active ROM Measurements
Dorsiflexion Endpoint (Active ROM)	Number	Enter the left wrist active range-of-motion endpoint measurement for dorsiflexion, in degrees.
Palmar Flexion Endpoint (Active ROM)	Number	Enter the left wrist active range-of-motion endpoint measurement for palmar flexion, in degrees.
Ulnar Deviation Endpoint (Active ROM)	Number	Enter the left wrist active range-of-motion endpoint measurement for ulnar deviation, in degrees.
Radial Deviation Endpoint (Active ROM)	Number	Enter the left wrist active range-of-motion endpoint measurement for radial deviation, in degrees.
Left Wrist - Active ROM Pain (Select All That Apply)
Dorsiflexion	Checkbox	Check this box if active left wrist dorsiflexion exhibited pain on examination.
Ulnar deviation	Checkbox	Check this box if active left wrist ulnar deviation exhibited pain on examination.
Palmar flexion	Checkbox	Check this box if active left wrist palmar flexion exhibited pain on examination.
Radial deviation	Checkbox	Check this box if active left wrist radial deviation exhibited pain on examination.
Left Wrist - Can Testing Be Performed
Yes	Radiobutton	Check this box if left wrist testing can be performed.
No	Radiobutton	Check this box if left wrist testing cannot be performed (e.g., medically contraindicated or would cause severe pain), and provide an explanation.
Explanation if Testing Cannot Be Performed	Text	Provide a detailed explanation for why left wrist testing cannot be performed or is medically contraindicated. Fill only if 'No' is 'Yes'. Depends on: No
Left Wrist - Does ROM Itself Contribute to Functional Loss?
Yes	Radiobutton	Check this box if the left wrist range of motion is abnormal and the limitation in range of motion itself contributes to functional loss.
No	Radiobutton	Check this box if the left wrist range of motion is abnormal but the limitation in range of motion itself does not contribute to functional loss.
Left Wrist ROM Functional Loss Explanation	Text	Provide an explanation of how the left wrist range of motion itself contributes to functional loss, if applicable. Fill only if 'Abnormal or outside of normal range', 'Yes' is 'Yes' (all). Depends on: Abnormal or outside of normal range, Yes
Left Wrist - Initial ROM Measurements (3A)
All normal	Radiobutton	Check this box if the Veteran’s left wrist initial range of motion measurements are normal.
Unable to test	Radiobutton	Check this box if you are unable to perform initial range of motion testing for the Veteran’s left wrist.
Abnormal or outside of normal range	Radiobutton	Check this box if the Veteran’s left wrist initial range of motion measurements are abnormal or outside the normal range.
Not indicated	Radiobutton	Check this box if initial range of motion measurements for the Veteran’s left wrist are not indicated.
Left Wrist Initial ROM Explanation	Text	Provide an explanation for why left wrist initial range of motion (ROM) testing was marked as "Unable to test" or "Not indicated." Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any). Depends on: Unable to test, Not indicated
Left Wrist - Limitation Degree Endpoints and Description
Dorsiflexion Limitation Degree Endpoint	Number	Enter the dorsiflexion degree at which limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM value listed above).
Palmar Flexion Limitation Degree Endpoint	Number	Enter the palmar flexion degree at which limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM value listed above).
Ulnar Deviation Limitation Degree Endpoint	Number	Enter the ulnar deviation degree at which limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM value listed above).
Radial Deviation Limitation Degree Endpoint	Number	Enter the radial deviation degree at which limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM value listed above).
Left Wrist Limitation Description	Text	Describe the factors (such as pain, weakness, fatigability, incoordination, or other) that specifically cause the left wrist limitation of motion and any relevant details.
Left Wrist - Passive ROM Measurements (and Same as Active ROM)
Passive ROM Dorsiflexion Endpoint (Degrees)	Number	Enter the left wrist passive range of motion dorsiflexion endpoint measurement in degrees. Fill only if 'Dorsiflexion (passive) - Same as active ROM' is 'No'. Depends on: Dorsiflexion (passive) - Same as active ROM
Dorsiflexion (passive) - Same as active ROM	Checkbox	Check this box if the passive dorsiflexion endpoint measurement is the same as the active ROM value.
Passive ROM Palmar Flexion Endpoint (Degrees)	Number	Enter the left wrist passive range of motion palmar flexion endpoint measurement in degrees. Fill only if 'Palmar flexion (passive) - Same as active ROM' is 'No'. Depends on: Palmar flexion (passive) - Same as active ROM
Palmar flexion (passive) - Same as active ROM	Checkbox	Check this box if the passive palmar flexion endpoint measurement is the same as the active ROM value.
Passive ROM Ulnar Deviation Endpoint (Degrees)	Number	Enter the left wrist passive range of motion ulnar deviation endpoint measurement in degrees. Fill only if 'Ulnar deviation (passive) - Same as active ROM' is 'No'. Depends on: Ulnar deviation (passive) - Same as active ROM
Ulnar deviation (passive) - Same as active ROM	Checkbox	Check this box if the passive ulnar deviation endpoint measurement is the same as the active ROM value.
Passive ROM Radial Deviation Endpoint (Degrees)	Text	Enter the left wrist passive range of motion radial deviation endpoint measurement in degrees. Fill only if 'Radial deviation (passive) - Same as active ROM' is 'No'. Depends on: Radial deviation (passive) - Same as active ROM
Radial deviation (passive) - Same as active ROM	Checkbox	Check this box if the passive radial deviation endpoint measurement is the same as the active ROM value.
Left Wrist - Passive ROM Pain (Select All That Apply)
Dorsiflexion	Checkbox	Check this box if pain was noted during passive left-wrist dorsiflexion range of motion testing.
Ulnar deviation	Checkbox	Check this box if pain was noted during passive left-wrist ulnar deviation range of motion testing.
Palmar flexion	Checkbox	Check this box if pain was noted during passive left-wrist palmar flexion range of motion testing.
Radial deviation	Checkbox	Check this box if pain was noted during passive left-wrist radial deviation range of motion testing.
Left Wrist - ROM Outside Normal but Normal for Veteran (Describe)
Left Wrist ROM Normal for Veteran Explanation	Text	Describe why the left wrist range of motion is outside the normal range but is considered normal for this Veteran (e.g., age, body habitus, neurologic disease, or other reason unrelated to the wrist condition). Fill only if 'Abnormal or outside of normal range' is 'Yes'. Depends on: Abnormal or outside of normal range
Left Wrist - Unclaimed Joint Status
Damaged	Radiobutton	Check this box if the left wrist is the unclaimed joint and it is damaged.
Undamaged	Radiobutton	Check this box if the left wrist is the unclaimed joint and it is undamaged.
Left Wrist Ankylosis Present
Yes	Radiobutton	Check this box if there is ankylosis of the left wrist.
No	Radiobutton	Check this box if there is no ankylosis of the left wrist.
Left Wrist Ankylosis Severity
Extremely unfavorable	Checkbox	Check this box if the Veteran’s left wrist ankylosis is extremely unfavorable. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Unfavorable, in any degree of palmar flexion	Checkbox	Check this box if the Veteran’s left wrist ankylosis is unfavorable and fixed in any degree of palmar flexion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Palmar Flexion (Degrees)	Text	Enter the number of degrees of palmar flexion present if the wrist ankylosis is unfavorable in any degree of palmar flexion. Fill only if 'Unfavorable, in any degree of palmar flexion' is 'Yes'. Depends on: Unfavorable, in any degree of palmar flexion
Unfavorable, with ulnar deviation	Checkbox	Check this box if the Veteran’s left wrist ankylosis is unfavorable and fixed with ulnar deviation. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Ulnar Deviation (Degrees)	Text	Enter the number of degrees of ulnar deviation present if the wrist ankylosis is unfavorable with ulnar deviation. Fill only if 'Unfavorable, with ulnar deviation' is 'Yes'. Depends on: Unfavorable, with ulnar deviation
Unfavorable, with radial deviation	Checkbox	Check this box if the Veteran’s left wrist ankylosis is unfavorable and fixed with radial deviation. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Radial Deviation (Degrees)	Text	Enter the number of degrees of radial deviation present if the wrist ankylosis is unfavorable with radial deviation. Fill only if 'Unfavorable, with radial deviation' is 'Yes'. Depends on: Unfavorable, with radial deviation
Any other position except favorable	Checkbox	Check this box if the Veteran’s left wrist ankylosis is present in a position that is not favorable but does not meet the listed unfavorable criteria above. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Ankylosis Position Description	Text	Describe the wrist position if ankylosis is present in any other position except favorable. Fill only if 'Any other position except favorable' is 'Yes'. Depends on: Any other position except favorable
Favorable in 20 to 30 degrees dorsiflexion	Checkbox	Check this box if the Veteran’s left wrist ankylosis is favorable and fixed in 20 to 30 degrees of dorsiflexion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Wrist Crepitus Evidence
Yes	Radiobutton	Check this box if there is objective evidence of crepitus in the left wrist.
No	Radiobutton	Check this box if there is no objective evidence of crepitus in the left wrist.
Left Wrist Observed Repetitive-Use ROM Testing
Yes	Radiobutton	Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions for the left wrist.
No	Radiobutton	Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions for the left wrist.
Repetitive-Use Testing Not Performed Explanation (Left Wrist)	Text	Explain why repetitive-use testing with at least three repetitions could not be performed for the left wrist. Fill only if 'No' is 'Yes'. Depends on: No
Left Wrist Pain Evidence and Impact
Evidence of pain – Yes	Radiobutton	Check this box if there is evidence of pain in the left wrist.
Evidence of pain – No	Radiobutton	Check this box if there is no evidence of pain in the left wrist.
Pain with weight-bearing	Checkbox	Check this box if left wrist pain is present during weight-bearing. Fill only if 'Evidence of pain – Yes' is 'Yes'. Depends on: Evidence of pain – Yes
Pain with nonweight-bearing	Checkbox	Check this box if left wrist pain is present during nonweight-bearing. Fill only if 'Evidence of pain – Yes' is 'Yes'. Depends on: Evidence of pain – Yes
Pain with active motion	Checkbox	Check this box if left wrist pain occurs with active motion (movement performed by the patient). Fill only if 'Evidence of pain – Yes' is 'Yes'. Depends on: Evidence of pain – Yes
Pain with passive motion	Checkbox	Check this box if left wrist pain occurs with passive motion (movement performed by the examiner). Fill only if 'Evidence of pain – Yes' is 'Yes'. Depends on: Evidence of pain – Yes
Pain at rest/non-movement	Checkbox	Check this box if left wrist pain is present at rest or when the wrist is not moving. Fill only if 'Evidence of pain – Yes' is 'Yes'. Depends on: Evidence of pain – Yes
Pain does not result in/cause functional loss	Checkbox	Check this box if left wrist pain is present but does not result in or cause functional loss. Fill only if 'Evidence of pain – Yes' is 'Yes'. Depends on: Evidence of pain – Yes
Pain causes functional loss	Checkbox	Check this box if left wrist pain causes functional loss (and describe it in the comments box).
Left Wrist Pain Comments	Text	Enter any additional comments describing the evidence of left wrist pain and how it affects function, including relevant details such as circumstances, severity, and impact on activities. Fill only if 'Pain causes functional loss' is 'Yes'. Depends on: Pain causes functional loss
Left Wrist ROM Endpoints (Limitation Factors)
Dorsiflexion Degree Endpoint	Number	Enter the left wrist dorsiflexion degree endpoint attributable to pain, weakness, fatigability, incoordination, or other limiting factors (if different than above). Fill only if 'Dorsiflexion endpoint (70 degrees)' differs from the value reported above. Depends on: Dorsiflexion Endpoint (Active ROM)
Palmar Flexion Degree Endpoint	Number	Enter the left wrist palmar flexion degree endpoint attributable to pain, weakness, fatigability, incoordination, or other limiting factors (if different than above). Fill only if 'Palmar flexion endpoint (80 degrees)' differs from the value reported above. Depends on: Palmar Flexion Endpoint (Active ROM)
Ulnar Deviation Degree Endpoint	Number	Enter the left wrist ulnar deviation degree endpoint attributable to pain, weakness, fatigability, incoordination, or other limiting factors (if different than above). Fill only if 'Ulnar deviation endpoint (45 degrees)' differs from the value reported above. Depends on: Ulnar Deviation Endpoint (Active ROM)
Radial Deviation Degree Endpoint	Number	Enter the left wrist radial deviation degree endpoint attributable to pain, weakness, fatigability, incoordination, or other limiting factors (if different than above). Fill only if 'Radial deviation endpoint (20 degrees)' differs from the value reported above. Depends on: Radial Deviation Endpoint (Active ROM)
Limitation Factors Description	Text	Describe how pain, weakness, fatigability, incoordination, or other factors limit left wrist range of motion and the degree(s) at which the limitation occurs.
Left Wrist Tenderness/Pain on Palpation
Yes — localized tenderness/pain on palpation (Left wrist)	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the left wrist joint or associated soft tissue.
No — localized tenderness/pain on palpation (Left wrist)	Radiobutton	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the left wrist joint or associated soft tissue.
Left wrist tenderness/pain on palpation explanation	Text	Explain the localized tenderness or pain on palpation of the left wrist or associated soft tissue, including the location, severity, and relationship to the condition(s). Fill only if 'Yes — localized tenderness/pain on palpation (Left wrist)' is 'Yes'. Depends on: Yes — localized tenderness/pain on palpation (Left wrist)
Loss of Effective Function Details (Q9B Summary)
Loss of Effective Function Summary	Text	For each affected extremity, describe the condition causing loss of function, explain the loss of effective function, and provide brief specific examples. Fill only if 'Right upper', 'Left upper' is 'Yes' (any). Depends on: Right upper, Left upper
Myositis Diagnosis
Myositis	Checkbox	Check this box if the claimed condition includes a diagnosis of myositis.
Side affected – Right	Radiobutton	Check this box if the myositis affects the right side/wrist only. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Side affected – Left	Radiobutton	Check this box if the myositis affects the left side/wrist only. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Side affected – Both	Radiobutton	Check this box if the myositis affects both sides/wrists. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis ICD Code	Text	Enter the ICD diagnostic code for the myositis diagnosis. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis Date of Diagnosis (Right)	Date	Enter the date myositis was diagnosed for the right side. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis Date of Diagnosis (Left)	Date	Enter the date myositis was diagnosed for the left side. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
No Current Diagnosis Checkbox (1B)
No current diagnosis for claimed condition(s)	Checkbox	Check this box if the Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.
Osteitis deformans Diagnosis
Osteitis deformans	Checkbox	Check this box if the Veteran has a diagnosis of osteitis deformans (Paget disease) associated with the claimed condition.
Side affected: Right	Radiobutton	Check this box if osteitis deformans affects the right side/wrist. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Side affected: Left	Radiobutton	Check this box if osteitis deformans affects the left side/wrist. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Side affected: Both	Radiobutton	Check this box if osteitis deformans affects both sides/wrists. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans ICD Code	Text	Enter the ICD diagnosis code associated with osteitis deformans. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans Date of Diagnosis (Right)	Date	Enter the date osteitis deformans was diagnosed for the right side. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans Date of Diagnosis (Left)	Date	Enter the date osteitis deformans was diagnosed for the left side. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteomalacia, residuals of Diagnosis
Osteomalacia, residuals of	Checkbox	Check this box if the Veteran has a diagnosis of osteomalacia with residuals associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the osteomalacia residuals affect the right wrist/hand/upper extremity. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Side affected: Left	Radiobutton	Check this box if the osteomalacia residuals affect the left wrist/hand/upper extremity. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Side affected: Both	Radiobutton	Check this box if the osteomalacia residuals affect both the right and left wrists/hands/upper extremities. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals ICD Code	Text	Enter the ICD diagnosis code for osteomalacia with residuals. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals Date of Diagnosis (Right)	Date	Enter the date of diagnosis for osteomalacia with residuals affecting the right side. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals Date of Diagnosis (Left)	Date	Enter the date of diagnosis for osteomalacia with residuals affecting the left side. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteoporosis, residuals of Diagnosis
Osteoporosis, residuals of	Checkbox	Check this box if the Veteran has a diagnosis of residuals of osteoporosis associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the osteoporosis residuals affect the right wrist/hand only. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Left	Radiobutton	Check this box if the osteoporosis residuals affect the left wrist/hand only. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Both	Radiobutton	Check this box if the osteoporosis residuals affect both the right and left wrists/hands. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis ICD Code	Text	Enter the ICD code corresponding to the Veteran's osteoporosis diagnosis. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with osteoporosis affecting the right side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with osteoporosis affecting the left side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Other Assistive Device Description and Frequency of Use
Other assistive device (describe)	Checkbox	Check this box if the Veteran uses an assistive device not listed, and provide the device description on the line. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Assistive Device Description	Text	Describe the other assistive device the Veteran uses (if not a brace). Fill only if 'Other assistive device (describe)' is 'Yes'. Depends on: Other assistive device (describe)
Other assistive device frequency: Occasional	Radiobutton	Check this box if the other assistive device is used occasionally. Fill only if 'Other assistive device (describe)' is 'Yes'. Depends on: Other assistive device (describe)
Other assistive device frequency: Regular	Radiobutton	Check this box if the other assistive device is used regularly. Fill only if 'Other assistive device (describe)' is 'Yes'. Depends on: Other assistive device (describe)
Other assistive device frequency: Constant	Radiobutton	Check this box if the other assistive device is used constantly. Fill only if 'Other assistive device (describe)' is 'Yes'. Depends on: Other assistive device (describe)
Other Diagnoses (Specify)
Other (specify)	Checkbox	Check this box if the Veteran has a wrist-related diagnosis not listed above and you will enter it in the provided “Other diagnosis” line.
Other Diagnosis #1	Text	Enter the name of the first additional wrist-related diagnosis not listed elsewhere on the form. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 – Side affected: Right	Radiobutton	Select this option if the first “Other diagnosis” affects the right wrist/hand only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 – Side affected: Left	Radiobutton	Select this option if the first “Other diagnosis” affects the left wrist/hand only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 – Side affected: Both	Radiobutton	Select this option if the first “Other diagnosis” affects both wrists/hands. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 ICD Code	Text	Enter the ICD code associated with Other Diagnosis #1, if known. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 Date of Diagnosis (Right)	Date	Enter the diagnosis date for Other Diagnosis #1 for the right wrist, if applicable. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 Date of Diagnosis (Left)	Date	Enter the diagnosis date for Other Diagnosis #1 for the left wrist, if applicable. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2	Text	Enter the name of the second additional wrist-related diagnosis not listed elsewhere on the form. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 – Side affected: Right	Radiobutton	Select this option if the second “Other diagnosis” affects the right wrist/hand only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 – Side affected: Left	Radiobutton	Select this option if the second “Other diagnosis” affects the left wrist/hand only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 – Side affected: Both	Radiobutton	Select this option if the second “Other diagnosis” affects both wrists/hands. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2 ICD Code	Text	Enter the ICD code associated with Other Diagnosis #2, if known. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2 Date of Diagnosis (Right)	Date	Enter the diagnosis date for Other Diagnosis #2 for the right wrist, if applicable. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2 Date of Diagnosis (Left)	Date	Enter the diagnosis date for Other Diagnosis #2 for the left wrist, if applicable. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other specified arthropathy (excluding gout) Diagnosis
Other specified forms of arthropathy (excluding gout)	Checkbox	Check this box if the Veteran has a diagnosis of an arthropathy not otherwise listed on the form (excluding gout), and specify the condition.
Side affected: Right	Radiobutton	Check this box if the other specified arthropathy affects the right wrist/side. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Side affected: Left	Radiobutton	Check this box if the other specified arthropathy affects the left wrist/side. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Side affected: Both	Radiobutton	Check this box if the other specified arthropathy affects both wrists/sides. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Other specified arthropathy ICD code	Text	Enter the ICD diagnostic code for the other specified arthropathy (excluding gout). Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Date of diagnosis (right)	Date	Enter the date this other specified arthropathy (excluding gout) was diagnosed for the right side. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Date of diagnosis (left)	Date	Enter the date this other specified arthropathy (excluding gout) was diagnosed for the left side. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Other specified arthropathy (excluding gout) description	Text	Specify the type or diagnosis name of the other specified arthropathy (excluding gout). Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Patient/Veteran Identification
Patient/Veteran Name	Text	Enter the full name of the patient/veteran.
Patient/Veteran Social Security Number	Text	Enter the patient/veteran's Social Security number.
Date of Examination	Date	Enter the date the examination was performed.
Post-traumatic arthritis Diagnosis
Post-traumatic arthritis	Checkbox	Check this box if the Veteran has a diagnosis of post-traumatic arthritis associated with the claimed condition(s).
Post-traumatic arthritis - Right	Radiobutton	Check this box if the post-traumatic arthritis affects the right wrist/side. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis - Left	Radiobutton	Check this box if the post-traumatic arthritis affects the left wrist/side. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis - Both	Radiobutton	Check this box if the post-traumatic arthritis affects both wrists/sides. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis ICD code	Text	Enter the ICD diagnosis code for the post-traumatic arthritis condition. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis diagnosis date (Right)	Date	Provide the date the Veteran was diagnosed with post-traumatic arthritis affecting the right wrist. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis diagnosis date (Left)	Date	Provide the date the Veteran was diagnosed with post-traumatic arthritis affecting the left wrist. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Questionnaire Requested By (Veteran/Third Party/Other)
Veteran/Claimant	Checkbox	Check this box if the disability benefits questionnaire is being completed at the request of the Veteran/Claimant.
Third party	Checkbox	Check this box if the questionnaire is being completed at the request of a third party (and list the organization(s) or individual(s) in the space provided).
Third Party Requester Name(s)	Text	Enter the name(s) of the third-party organization(s) or individual(s) who requested completion of this Disability Benefits Questionnaire. Fill only if 'Third party' is 'Yes'. Depends on: Third party
Other	Checkbox	Check this box if the questionnaire is being completed at the request of someone or for a reason not covered above, and describe the requester in the space provided.
Other Request Description	Text	Describe the other person or reason that requested completion of this Disability Benefits Questionnaire. Fill only if 'Other' is 'Yes'. Depends on: Other
Right - Additional loss after three repetitions
Yes	Radiobutton	Check this box if there is additional loss of function or range of motion after three repetitions (right side). Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if there is no additional loss of function or range of motion after three repetitions (right side). Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'. Depends on: Yes
Right dorsiflexion endpoint after 3 repetitions	Number	Enter the right wrist dorsiflexion endpoint (range of motion) measured after completing three repetitions, in degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right palmar flexion endpoint after 3 repetitions	Number	Enter the right wrist palmar flexion endpoint (range of motion) measured after completing three repetitions, in degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right ulnar deviation endpoint after 3 repetitions	Number	Enter the right wrist ulnar deviation endpoint (range of motion) measured after completing three repetitions, in degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right radial deviation endpoint after 3 repetitions	Number	Enter the right wrist radial deviation endpoint (range of motion) measured after completing three repetitions, in degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if selecting factors that cause functional loss is not applicable for the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Pain	Checkbox	Check this box if pain causes the additional functional loss after three repetitions on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability causes the additional functional loss after three repetitions on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness causes the additional functional loss after three repetitions on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes the additional functional loss after three repetitions on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination causes the additional functional loss after three repetitions on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other	Checkbox	Check this box if another factor (not listed) causes the additional functional loss after three repetitions on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right additional loss factor - Other (specify)	Text	If you selected “Other” as a factor causing functional loss after three repetitions, specify the other factor(s) here. Fill only if 'Other' is 'Yes'. Depends on: Other
Right - Repeated use over time: cite and discuss evidence
Repeated Use Over Time Evidence (Right)	Text	Cite and discuss the specific evidence supporting the estimated functional loss and range-of-motion limitations for the right joint with repeated use over time.
Right - Repeated use over time: estimated ROM after repeated use
Estimated dorsiflexion endpoint after repeated use (Right)	Number	Enter the estimated dorsiflexion endpoint in degrees for the right joint immediately after repeated use over time. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Estimated palmar flexion endpoint after repeated use (Right)	Number	Enter the estimated palmar flexion endpoint in degrees for the right joint immediately after repeated use over time. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Estimated ulnar deviation endpoint after repeated use (Right)	Number	Enter the estimated ulnar deviation endpoint in degrees for the right joint immediately after repeated use over time. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Estimated radial deviation endpoint after repeated use (Right)	Number	Enter the estimated radial deviation endpoint in degrees for the right joint immediately after repeated use over time. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Right - Repeated use over time: functional loss factors
N/A	Checkbox	Check this box if no specific factor (pain, fatigability, weakness, lack of endurance, incoordination, or other) is causing functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Pain	Checkbox	Check this box if pain contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Fatigability	Checkbox	Check this box if fatigability contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Weakness	Checkbox	Check this box if weakness contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Lack of endurance	Checkbox	Check this box if lack of endurance contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Incoordination	Checkbox	Check this box if incoordination contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Other	Checkbox	Check this box if a different factor (not listed) contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests significant limitation with repeated use over time - Yes' is 'Yes'. Depends on: Procured evidence suggests significant limitation with repeated use over time - Yes
Other functional loss factor (Right)	Text	Describe any other factor causing functional loss with repeated use over time for the right side that is not listed among the checkboxes. Fill only if 'Other' is 'Yes'. Depends on: Other
Right - Repeated use over time: immediate exam & evidence yes/no
Examined immediately after repeated use over time - Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time.
Examined immediately after repeated use over time - No	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time.
Procured evidence suggests significant limitation with repeated use over time - Yes	Radiobutton	Check this box if procured evidence (e.g., the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.
Procured evidence suggests significant limitation with repeated use over time - No	Radiobutton	Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.
Right Column Additional Contributing Factors (Checkboxes + Other Text)
None	Checkbox	Check this box if there are no additional factors contributing to the disability beyond those already addressed.
Interference with standing	Checkbox	Check this box if the disability causes difficulty or limitation with standing.
Interference with sitting	Checkbox	Check this box if the disability causes difficulty or limitation with sitting.
Disturbance of locomotion	Checkbox	Check this box if the disability affects walking or movement from place to place (e.g., gait disturbance).
Swelling	Checkbox	Check this box if swelling is an additional contributing factor to the disability.
Less movement than normal	Checkbox	Check this box if the joint/body part has decreased movement or range of motion compared to normal.
Deformity	Checkbox	Check this box if there is a visible or measurable deformity contributing to the disability.
Weakened movement	Checkbox	Check this box if weakness or reduced strength contributes to limited movement or function.
More movement than normal	Checkbox	Check this box if the joint/body part has increased movement or instability (hypermobility) compared to normal.
Instability of station	Checkbox	Check this box if the disability causes unsteadiness or difficulty maintaining balance while standing or moving.
Atrophy of disuse	Checkbox	Check this box if muscle wasting due to disuse is present and contributes to the disability.
Other, describe	Checkbox	Check this box if there is another additional contributing factor not listed and you will describe it in the space provided.
Other Contributing Factor (Describe)	Text	Describe any other additional factor contributing to the disability that is not covered by the listed options. Fill only if 'Other, describe' is 'Yes'. Depends on: Other, describe
Right Column Additional Contributing Factors Narrative
Additional Contributing Factors Description	Text	Describe any additional factors contributing to the disability, including details for any selected items and any other contributing factors not listed.
Right Column Flare-up Evidence Narrative
Flare-up Evidence Narrative	Text	Cite and discuss the procurable evidence supporting the flare-up findings, ensuring the discussion is specific to the case. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Right Column Flare-up Functional Loss Causes (Checkboxes + Other Text)
N/A	Checkbox	Check this box if no specific factors apply as causes of the reported functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Pain	Checkbox	Check this box if pain causes or contributes to the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability (easy tiring) causes or contributes to the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness causes or contributes to the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes or contributes to the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination causes or contributes to the functional loss with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Other	Checkbox	Check this box if another factor not listed causes or contributes to the functional loss with repeated use over time (and specify it in the provided space). Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Other Functional Loss Cause	Text	Enter the other factor(s) that cause functional loss during flare-ups if you selected "Other." Fill only if 'Other' is 'Yes'. Depends on: Other
Right Column Flare-up Yes/No Questions
Yes — Exam conducted during a flare-up	Radiobutton	Check this box if the examination is being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
No — Exam not conducted during a flare-up	Radiobutton	Check this box if the examination is not being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Yes — Evidence suggests functional loss with repeated use over time	Radiobutton	Check this box if procured evidence (e.g., the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
No — Evidence does not suggest functional loss with repeated use over time	Radiobutton	Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Right Column Repeated-Use Range of Motion Estimates
Dorsiflexion Endpoint After Repeated Use (Degrees)	Text	Enter the estimated dorsiflexion endpoint range of motion in degrees for this joint immediately after repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Palmar Flexion Endpoint After Repeated Use (Degrees)	Text	Enter the estimated palmar flexion endpoint range of motion in degrees for this joint immediately after repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Ulnar Deviation Endpoint After Repeated Use (Degrees)	Text	Enter the estimated ulnar deviation endpoint range of motion in degrees for this joint immediately after repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Radial Deviation Endpoint After Repeated Use (Degrees)	Text	Enter the estimated radial deviation endpoint range of motion in degrees for this joint immediately after repeated use over time. Fill only if 'Does the Veteran report flare-ups of the wrist?' is 'Yes'. Depends on: Yes
Right Upper Extremity Atrophy Measurements
Right upper extremity	Checkbox	Check this box when documenting muscle atrophy measurements for the Veteran’s right upper extremity (and then specify the measurement location and record normal vs. atrophied side measurements).
Measurement Location Description (Right Upper Extremity)	Text	Enter the specific anatomical location and reference point where the right upper extremity circumference measurements were taken (e.g., distance from a joint crease). Fill only if 'Right upper extremity' is 'Yes'. Depends on: Right upper extremity
Circumference of More Normal Side (cm)	Number	Enter the circumference measurement of the more normal (non-atrophied) side for comparison. Fill only if 'Right upper extremity' is 'Yes'. Depends on: Right upper extremity
Circumference of Atrophied Side (cm)	Number	Enter the circumference measurement of the atrophied side taken at the same location as the normal side measurement. Fill only if 'Right upper extremity' is 'Yes'. Depends on: Right upper extremity
Right Upper Extremity Muscle Atrophy
4A. Muscle atrophy - Yes	Radiobutton	Check this box if the Veteran has muscle atrophy in the right upper extremity.
4A. Muscle atrophy - No	Radiobutton	Check this box if the Veteran does not have muscle atrophy in the right upper extremity.
4B. Due to claimed condition (diagnosis section) - Yes	Radiobutton	Check this box if the right upper extremity muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if '4A. Muscle atrophy - Yes' is 'Yes'. Depends on: 4A. Muscle atrophy - Yes
4B. Due to claimed condition (diagnosis section) - No	Radiobutton	Check this box if the right upper extremity muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if '4A. Muscle atrophy - Yes' is 'Yes'. Depends on: 4A. Muscle atrophy - Yes
Rationale if Not Due to Claimed Condition	Text	Provide the medical rationale explaining why the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if '4B. Due to claimed condition (diagnosis section) - No' is 'Yes'. Depends on: 4B. Due to claimed condition (diagnosis section) - No
Right Wrist - Active ROM Measurements
Dorsiflexion Endpoint	Number	Enter the measured active range-of-motion endpoint for right wrist dorsiflexion in degrees.
Palmar Flexion Endpoint	Number	Enter the measured active range-of-motion endpoint for right wrist palmar flexion in degrees.
Ulnar Deviation Endpoint	Number	Enter the measured active range-of-motion endpoint for right wrist ulnar deviation in degrees.
Radial Deviation Endpoint	Number	Enter the measured active range-of-motion endpoint for right wrist radial deviation in degrees.
Right Wrist - Active ROM Pain (Select All That Apply)
Dorsiflexion	Checkbox	Check this box if the right wrist exhibited pain during active dorsiflexion range-of-motion testing.
Ulnar deviation	Checkbox	Check this box if the right wrist exhibited pain during active ulnar deviation range-of-motion testing.
Palmar flexion	Checkbox	Check this box if the right wrist exhibited pain during active palmar flexion range-of-motion testing.
Radial deviation	Checkbox	Check this box if the right wrist exhibited pain during active radial deviation range-of-motion testing.
Right Wrist - Can Testing Be Performed
Yes	Radiobutton	Check this box if right wrist testing can be performed.
No	Radiobutton	Check this box if right wrist testing cannot be performed or is medically contraindicated (and provide an explanation).
Explanation if Testing Cannot Be Performed	Text	Provide the reason testing cannot be performed or is medically contraindicated for the right wrist. Fill only if 'No' is 'Yes'. Depends on: No
Right Wrist - Does ROM Itself Contribute to Functional Loss?
Yes	Radiobutton	Check this box if the right wrist range of motion abnormality itself contributes to a functional loss.
No	Radiobutton	Check this box if the right wrist range of motion abnormality does not itself contribute to a functional loss.
ROM Contribution to Functional Loss Explanation (Right Wrist)	Text	Provide an explanation of how the right wrist range of motion itself contributes to the Veteran’s functional loss, if applicable. Fill only if 'Abnormal or outside of normal range', 'Yes' is 'Yes' (all). Depends on: Abnormal or outside of normal range, Yes
Right Wrist - Initial ROM Measurements (3A)
All normal	Radiobutton	Check this box if the Veteran’s initial right wrist range of motion (ROM) measurements are normal.
Unable to test	Radiobutton	Check this box if you could not perform initial right wrist ROM testing.
Abnormal or outside of normal range	Radiobutton	Check this box if the Veteran’s initial right wrist ROM measurements are abnormal or outside the normal range.
Not indicated	Radiobutton	Check this box if initial right wrist ROM measurements are not indicated for this evaluation.
Unable to Test/Not Indicated Explanation (Right Wrist)	Text	Provide the reason the right wrist initial range-of-motion measurement was unable to be tested or was not indicated. Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any). Depends on: Unable to test, Not indicated
Right Wrist - Limitation Degree Endpoints and Description
Dorsiflexion limitation degree endpoint	Number	Enter the dorsiflexion degree endpoint attributable to the noted limiting factor(s) (if different than the dorsiflexion ROM value recorded above).
Palmar flexion limitation degree endpoint	Text	Enter the palmar flexion degree endpoint attributable to the noted limiting factor(s) (if different than the palmar flexion ROM value recorded above).
Ulnar deviation limitation degree endpoint	Number	Enter the ulnar deviation degree endpoint attributable to the noted limiting factor(s) (if different than the ulnar deviation ROM value recorded above).
Radial deviation limitation degree endpoint	Number	Enter the radial deviation degree endpoint attributable to the noted limiting factor(s) (if different than the radial deviation ROM value recorded above).
Limitation description	Text	Describe the factor(s) (e.g., pain, weakness, fatigability, incoordination, or other) causing limitation of motion and how they affect the right wrist range of motion.
Right Wrist - Passive ROM Measurements (and Same as Active ROM)
Passive ROM Dorsiflexion Endpoint (Degrees)	Number	Enter the right wrist passive dorsiflexion range-of-motion endpoint in degrees. Fill only if 'Dorsiflexion – Same as active ROM' is 'No'. Depends on: Dorsiflexion – Same as active ROM
Dorsiflexion – Same as active ROM	Checkbox	Check this box if the passive dorsiflexion range of motion is the same as the active dorsiflexion range of motion.
Passive ROM Palmar Flexion Endpoint (Degrees)	Number	Enter the right wrist passive palmar flexion range-of-motion endpoint in degrees. Fill only if 'Palmar flexion – Same as active ROM' is 'No'. Depends on: Palmar flexion – Same as active ROM
Palmar flexion – Same as active ROM	Checkbox	Check this box if the passive palmar flexion range of motion is the same as the active palmar flexion range of motion.
Passive ROM Ulnar Deviation Endpoint (Degrees)	Number	Enter the right wrist passive ulnar deviation range-of-motion endpoint in degrees. Fill only if 'Ulnar deviation – Same as active ROM' is 'No'. Depends on: Ulnar deviation – Same as active ROM
Ulnar deviation – Same as active ROM	Checkbox	Check this box if the passive ulnar deviation range of motion is the same as the active ulnar deviation range of motion.
Passive ROM Radial Deviation Endpoint (Degrees)	Number	Enter the right wrist passive radial deviation range-of-motion endpoint in degrees. Fill only if 'Radial deviation – Same as active ROM' is 'No'. Depends on: Radial deviation – Same as active ROM
Radial deviation – Same as active ROM	Checkbox	Check this box if the passive radial deviation range of motion is the same as the active radial deviation range of motion.
Right Wrist - Passive ROM Pain (Select All That Apply)
Dorsiflexion	Checkbox	Check this box if pain was noted on examination during passive right-wrist dorsiflexion range of motion.
Ulnar deviation	Checkbox	Check this box if pain was noted on examination during passive right-wrist ulnar deviation range of motion.
Palmar flexion	Checkbox	Check this box if pain was noted on examination during passive right-wrist palmar flexion range of motion.
Radial deviation	Checkbox	Check this box if pain was noted on examination during passive right-wrist radial deviation range of motion.
Right Wrist - ROM Outside Normal but Normal for Veteran (Describe)
Right Wrist ROM Outside Normal but Normal for Veteran - Description	Text	Describe why the right wrist range of motion is outside the normal range but is considered normal for this Veteran (e.g., due to age, body habitus, neurologic condition, or other factors). Fill only if 'Abnormal or outside of normal range' is 'Yes'. Depends on: Abnormal or outside of normal range
Right Wrist - Unclaimed Joint Status
Damaged	Radiobutton	Check this box if the unclaimed right wrist joint is damaged.
Undamaged	Radiobutton	Check this box if the unclaimed right wrist joint is undamaged.
Right Wrist Ankylosis Present
Yes	Radiobutton	Check this box if there is ankylosis (immobilization) of the right wrist.
No	Radiobutton	Check this box if there is no ankylosis of the right wrist.
Right Wrist Ankylosis Severity
Extremely unfavorable	Checkbox	Check this box if the Veteran’s right wrist ankylosis is extremely unfavorable. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Unfavorable (any degree of palmar flexion)	Checkbox	Check this box if the Veteran’s right wrist ankylosis is unfavorable and fixed in any degree of palmar flexion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Palmar Flexion Degrees (Unfavorable Ankylosis)	Text	Enter the number of degrees of palmar flexion for the right wrist if ankylosis is extremely unfavorable or unfavorable in any degree of palmar flexion. Fill only if 'Unfavorable (any degree of palmar flexion)' is 'Yes'. Depends on: Unfavorable (any degree of palmar flexion)
Unfavorable (with ulnar deviation)	Checkbox	Check this box if the Veteran’s right wrist ankylosis is unfavorable with ulnar deviation. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Ulnar Deviation Degrees (Unfavorable Ankylosis)	Text	Enter the number of degrees of ulnar deviation for the right wrist if ankylosis is unfavorable with ulnar deviation. Fill only if 'Unfavorable (with ulnar deviation)' is 'Yes'. Depends on: Unfavorable (with ulnar deviation)
Unfavorable (with radial deviation)	Checkbox	Check this box if the Veteran’s right wrist ankylosis is unfavorable with radial deviation. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Radial Deviation Degrees (Unfavorable Ankylosis)	Text	Enter the number of degrees of radial deviation for the right wrist if ankylosis is unfavorable with radial deviation. Fill only if 'Unfavorable (with radial deviation)' is 'Yes'. Depends on: Unfavorable (with radial deviation)
Any other position except favorable	Checkbox	Check this box if the Veteran’s right wrist ankylosis is in any other position that is not considered favorable. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Ankylosis Position Description	Text	Describe the right wrist position if ankylosis is in any other position except favorable. Fill only if 'Any other position except favorable' is 'Yes'. Depends on: Any other position except favorable
Favorable (20–30 degrees dorsiflexion)	Checkbox	Check this box if the Veteran’s right wrist ankylosis is favorable in 20 to 30 degrees of dorsiflexion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Wrist Crepitus Evidence
Crepitus evidence - Yes	Radiobutton	Check this box if there is objective evidence of crepitus in the right wrist on examination.
Crepitus evidence - No	Radiobutton	Check this box if there is no objective evidence of crepitus in the right wrist on examination.
Right Wrist Observed Repetitive-Use ROM Testing
Yes	Radiobutton	Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions for the right wrist.
No	Radiobutton	Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions for the right wrist.
Repetitive-Use Testing Not Performed Explanation (Right Wrist)	Text	Explain why the veteran was unable to perform right-wrist repetitive-use range-of-motion testing with at least three repetitions. Fill only if 'No' is 'Yes'. Depends on: No
Right Wrist Pain Evidence and Impact
Evidence of pain - Yes	Radiobutton	Check this box if there is evidence of pain in the right wrist.
Evidence of pain - No	Radiobutton	Check this box if there is no evidence of pain in the right wrist.
Pain with weight-bearing	Checkbox	Check this box if right wrist pain is evident during weight-bearing. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with nonweight-bearing	Checkbox	Check this box if right wrist pain is evident during nonweight-bearing. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with active motion	Checkbox	Check this box if right wrist pain is evident during active motion (the patient moves the wrist). Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with passive motion	Checkbox	Check this box if right wrist pain is evident during passive motion (the examiner moves the wrist). Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain at rest/non-movement	Checkbox	Check this box if right wrist pain is evident at rest or without movement. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain does not result in/cause functional loss	Checkbox	Check this box if the right wrist pain is present but does not result in or cause functional loss. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain causes functional loss	Checkbox	Check this box if right wrist pain causes functional loss (and provide details in the comments box below).
Right Wrist Pain Comments	Text	Enter any additional comments describing the evidence of right wrist pain and its impact on function (e.g., when it occurs, what provokes it, and resulting limitations). Fill only if 'Pain causes functional loss' is 'Yes'. Depends on: Pain causes functional loss
Right Wrist ROM Endpoints (Limitation Factors)
Dorsiflexion Degree Endpoint	Text	Enter the dorsiflexion degree endpoint for the right wrist if it differs from the value reported above. Fill only if 'Dorsiflexion endpoint (70 degrees)' differs from the value reported above. Depends on: Dorsiflexion Endpoint
Palmar Flexion Degree Endpoint	Text	Enter the palmar flexion degree endpoint for the right wrist if it differs from the value reported above. Fill only if 'Palmar flexion endpoint (80 degrees)' differs from the value reported above. Depends on: Palmar Flexion Endpoint
Ulnar Deviation Degree Endpoint	Text	Enter the ulnar deviation degree endpoint for the right wrist if it differs from the value reported above. Fill only if 'Ulnar deviation endpoint (45 degrees)' differs from the value reported above. Depends on: Ulnar Deviation Endpoint
Radial Deviation Degree Endpoint	Text	Enter the radial deviation degree endpoint for the right wrist if it differs from the value reported above. Fill only if 'Radial deviation endpoint (20 degrees)' differs from the value reported above. Depends on: Radial Deviation Endpoint
Limitation Factors Description	Text	Describe the factors (e.g., pain, weakness, fatigability, incoordination, or other) that limit right wrist motion and the degree(s) at which the limitation occurs.
Right Wrist Tenderness/Pain on Palpation
Yes	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the right wrist joint or associated soft tissue.
No	Radiobutton	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the right wrist joint or associated soft tissue.
Right Wrist Tenderness/Pain on Palpation Explanation	Text	Explain any localized tenderness or pain on palpation of the right wrist or associated soft tissue, including the location, severity, and relationship to the condition(s). Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION II - MEDICAL HISTORY
Wrist Condition History Summary	Text	Provide a brief summary of the Veteran’s wrist condition history, including when it began and how it has progressed over time.
Yes	Radiobutton	Check this box if the Veteran reports having flare-ups of the wrist.
No	Radiobutton	Check this box if the Veteran does not report having flare-ups of the wrist.
Wrist Flare-Ups Description	Text	Describe the Veteran’s wrist flare-ups, including frequency, duration, characteristics, triggers, relieving factors, and the severity and functional impact during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION XI - FUNCTIONAL IMPACT
Yes	Radiobutton	Check this box if the diagnosed condition(s) impact the Veteran’s ability to perform any type of occupational task (e.g., standing, walking, lifting, sitting).
No	Radiobutton	Check this box if the diagnosed condition(s) do not impact the Veteran’s ability to perform any type of occupational task.
Functional Impact Description	Text	Describe how the diagnosed condition(s) impact the veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting), including one or more examples. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION XII - REMARKS
Remarks	Text	Enter any additional remarks or explanations, identifying the section of the form the remark pertains to when appropriate. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'Yes'. Depends on: No current diagnosis for claimed condition(s)
Tendinitis Diagnosis
Tendinitis	Checkbox	Check this box if the Veteran has a current diagnosis of tendinitis related to the claimed condition. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinitis - Right	Radiobutton	Check this box if the tendinitis affects the right side/wrist. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Left	Radiobutton	Check this box if the tendinitis affects the left side/wrist. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Both	Radiobutton	Check this box if the tendinitis affects both sides/wrists. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis ICD Code	Text	Enter the ICD diagnosis code for the tendinitis condition. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Date of Diagnosis (Right)	Date	Enter the date the right-side tendinitis was diagnosed. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Date of Diagnosis (Left)	Date	Enter the date the left-side tendinitis was diagnosed. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinopathy (unspecified) Diagnosis
Tendinopathy (select one if known)	Checkbox	Check this box if the Veteran has a diagnosis of tendinopathy related to the claimed wrist condition.
Tendinopathy – Side affected: Right	Radiobutton	Check this box if the tendinopathy affects the right wrist. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy – Side affected: Left	Radiobutton	Check this box if the tendinopathy affects the left wrist. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy – Side affected: Both	Radiobutton	Check this box if the tendinopathy affects both wrists. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy ICD Code	Text	Enter the ICD diagnosis code for the Veteran’s tendinopathy. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy Date of Diagnosis (Right)	Date	Enter the date the Veteran’s right-sided tendinopathy was diagnosed. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy Date of Diagnosis (Left)	Date	Enter the date the Veteran’s left-sided tendinopathy was diagnosed. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tenosynovitis – Side affected: Right	Radiobutton	Check this box if tenosynovitis (as the tendinopathy type) affects the right wrist. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis – Side affected: Left	Radiobutton	Check this box if tenosynovitis (as the tendinopathy type) affects the left wrist. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis – Side affected: Both	Radiobutton	Check this box if tenosynovitis (as the tendinopathy type) affects both wrists. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tendinosis Diagnosis
Tendinosis	Checkbox	Check this box if the Veteran has a current diagnosis of tendinosis related to the claimed wrist condition.
Tendinosis – Side affected: Right	Radiobutton	Select this option if the tendinosis affects the right wrist only. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis – Side affected: Left	Radiobutton	Select this option if the tendinosis affects the left wrist only. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis – Side affected: Both	Radiobutton	Select this option if the tendinosis affects both wrists. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis ICD Code	Text	Enter the ICD diagnosis code for the tendinosis condition. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Date of Diagnosis (Right)	Date	Enter the date the tendinosis diagnosis was made for the right side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Date of Diagnosis (Left)	Date	Enter the date the tendinosis diagnosis was made for the left side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tenosynovitis Diagnosis
Arthritis, syphilitic	Checkbox	Check this box if the Veteran has a current diagnosis of syphilitic arthritis associated with the claimed condition(s).
Right (side affected)	Radiobutton	Select this option if the syphilitic arthritis diagnosis affects the right side. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Left (side affected)	Radiobutton	Select this option if the syphilitic arthritis diagnosis affects the left side. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Tenosynovitis	Checkbox	Check this box if the Veteran has a current diagnosis of tenosynovitis associated with the claimed condition(s). Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tenosynovitis ICD Code	Text	Enter the ICD diagnostic code associated with the tenosynovitis diagnosis. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Date of Diagnosis (Right)	Date	Enter the date the tenosynovitis diagnosis was made for the right side. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Date of Diagnosis (Left)	Date	Enter the date the tenosynovitis diagnosis was made for the left side. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Triangular fibrocartilaginous complex (TFCC) injury Diagnosis
Triangular fibrocartilaginous complex (TFCC) injury	Checkbox	Check this box if the Veteran has a diagnosis of a triangular fibrocartilaginous complex (TFCC) injury associated with the claimed condition(s).
TFCC injury – Side affected: Right	Radiobutton	Check this box if the diagnosed TFCC injury affects the right wrist. Fill only if 'Triangular fibrocartilaginous complex (TFCC) injury' is 'Yes'. Depends on: Triangular fibrocartilaginous complex (TFCC) injury
TFCC injury – Side affected: Left	Radiobutton	Check this box if the diagnosed TFCC injury affects the left wrist. Fill only if 'Triangular fibrocartilaginous complex (TFCC) injury' is 'Yes'. Depends on: Triangular fibrocartilaginous complex (TFCC) injury
TFCC injury – Side affected: Both	Radiobutton	Check this box if the diagnosed TFCC injury affects both wrists. Fill only if 'Triangular fibrocartilaginous complex (TFCC) injury' is 'Yes'. Depends on: Triangular fibrocartilaginous complex (TFCC) injury
TFCC Injury ICD Code	Text	Enter the ICD diagnosis code for the triangular fibrocartilaginous complex (TFCC) injury. Fill only if 'Triangular fibrocartilaginous complex (TFCC) injury' is 'Yes'. Depends on: Triangular fibrocartilaginous complex (TFCC) injury
TFCC Injury Diagnosis Date (Right)	Date	Enter the date the triangular fibrocartilaginous complex (TFCC) injury was diagnosed for the right side. Fill only if 'Triangular fibrocartilaginous complex (TFCC) injury' is 'Yes'. Depends on: Triangular fibrocartilaginous complex (TFCC) injury
TFCC Injury Diagnosis Date (Left)	Date	Enter the date the triangular fibrocartilaginous complex (TFCC) injury was diagnosed for the left side. Fill only if 'Triangular fibrocartilaginous complex (TFCC) injury' is 'Yes'. Depends on: Triangular fibrocartilaginous complex (TFCC) injury
VA Healthcare Provider (Yes/No)
Yes	Radiobutton	Check this box if you are a VA Healthcare provider.
No	Radiobutton	Check this box if you are not a VA Healthcare provider.
Veteran Examined in Person (Yes/No and If No, How Conducted)
Yes	Radiobutton	Check this box if the Veteran was examined in person.
No	Radiobutton	Check this box if the Veteran was not examined in person.
If No, How Examination Was Conducted	Text	If the Veteran was not examined in person, describe how the examination was conducted (e.g., telehealth, records review, or other method). Fill only if 'No' is 'Yes'. Depends on: No
Veteran Regularly Seen in Your Clinic (Yes/No)
Yes	Radiobutton	Check this box if the Veteran is regularly seen as a patient in your clinic.
No	Radiobutton	Check this box if the Veteran is not regularly seen as a patient in your clinic.
Wrist arthroplasty (total/ulnar head replacement) Diagnosis
Wrist arthroplasty (total/ulnar head replacement)	Checkbox	Check this box if the Veteran has a diagnosis/history of wrist arthroplasty (total wrist or ulnar head replacement) associated with the claimed condition.
Side affected: Right	Radiobutton	Select this option if the wrist arthroplasty affects the right wrist. Fill only if 'Wrist arthroplasty (total/ulnar head replacement)' is 'Yes'. Depends on: Wrist arthroplasty (total/ulnar head replacement)
Side affected: Left	Radiobutton	Select this option if the wrist arthroplasty affects the left wrist. Fill only if 'Wrist arthroplasty (total/ulnar head replacement)' is 'Yes'. Depends on: Wrist arthroplasty (total/ulnar head replacement)
Side affected: Both	Radiobutton	Select this option if the wrist arthroplasty affects both wrists. Fill only if 'Wrist arthroplasty (total/ulnar head replacement)' is 'Yes'. Depends on: Wrist arthroplasty (total/ulnar head replacement)
Wrist arthroplasty ICD code	Text	Enter the ICD diagnosis code for the wrist arthroplasty (total/ulnar head replacement) condition. Fill only if 'Wrist arthroplasty (total/ulnar head replacement)' is 'Yes'. Depends on: Wrist arthroplasty (total/ulnar head replacement)
Wrist arthroplasty diagnosis date (Right)	Date	Enter the date the wrist arthroplasty (total/ulnar head replacement) diagnosis was made for the right wrist. Fill only if 'Wrist arthroplasty (total/ulnar head replacement)' is 'Yes'. Depends on: Wrist arthroplasty (total/ulnar head replacement)
Wrist arthroplasty diagnosis date (Left)	Date	Enter the date the wrist arthroplasty (total/ulnar head replacement) diagnosis was made for the left wrist. Fill only if 'Wrist arthroplasty (total/ulnar head replacement)' is 'Yes'. Depends on: Wrist arthroplasty (total/ulnar head replacement)
Wrist sprain, chronic Diagnosis
Wrist sprain, chronic	Checkbox	Check this box if the Veteran has a current diagnosis of chronic wrist sprain associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the chronic wrist sprain affects the right wrist. Fill only if 'Wrist sprain, chronic' is 'Yes'. Depends on: Wrist sprain, chronic
Side affected: Left	Radiobutton	Check this box if the chronic wrist sprain affects the left wrist. Fill only if 'Wrist sprain, chronic' is 'Yes'. Depends on: Wrist sprain, chronic
Side affected: Both	Radiobutton	Check this box if the chronic wrist sprain affects both wrists. Fill only if 'Wrist sprain, chronic' is 'Yes'. Depends on: Wrist sprain, chronic
Wrist Sprain, Chronic ICD Code	Text	Enter the ICD diagnostic code for the Veteran’s chronic wrist sprain diagnosis. Fill only if 'Wrist sprain, chronic' is 'Yes'. Depends on: Wrist sprain, chronic
Wrist Sprain, Chronic Date of Diagnosis (Right)	Date	Enter the date the chronic wrist sprain was diagnosed for the right wrist. Fill only if 'Wrist sprain, chronic' is 'Yes'. Depends on: Wrist sprain, chronic
Wrist Sprain, Chronic Date of Diagnosis (Left)	Date	Enter the date the chronic wrist sprain was diagnosed for the left wrist. Fill only if 'Wrist sprain, chronic' is 'Yes'. Depends on: Wrist sprain, chronic

Wrist Conditions Disability Benefits Questionnaire (DBQ) Instructions